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EBM Depression 
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Mood disorders can be thought of as occurring along a spectrum with a single major 
depressive illness and bipolar type 1 disorder at the extremes.1 
Bipolar Disorder Type 1
Single Major
Psychotic Major
(Mania & Depression)
Depressive Episode
Depressive Disorder
Chronic Major
Depressive Disorder
Recurrent Major
Bipolar Disorder Type II
(Hypomania & Depression)
This protocol deals with unipolar mood disorders.  These are characterised by 
recurrent episodes of depression without intervening episodes of mania or 
hypomania.  Bipolar disorders, persistent mood disorders (including cyclothymia and 
dysthymia), schizoaffective disorders and anxiety disorders are described in 
separate protocols. 
Unipolar mood disorders may be primary, or secondary (to medical conditions or 
misuse of alcohol and other substances). 
Primary unipolar mood disorders can be divided into: 
  Depressive episode - single episode 
  Recurrent depressive disorder - recurrent episodes 
  Mixed anxiety and depressive disorder. 
Each depressive episode may be: 
  Moderate or severe 
  If severe, with or without psychotic symptoms. 
This protocol also includes: 
  Other mood disorders not covered in other protocols, (Seasonal Affective 
Disorder, Post-natal Depression and Depression in the Elderly) and  
  Conditions which may be associated with mood disorders as well as other 
psychiatric disorders.  Suicide and Deliberate Self-Harm are described in 
appendices A and B respectively.  Bereavement is discussed in Appendix C. 
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Historically mood disorders were often referred to as affective disorders.  The term 
'affective' has been replaced with 'mood' in both international classification systems 
of mental disorders (ICD-102 and DSM IV)3 in order to emphasise the duration of the 
episodes of depression. 
The distinction between mood and affect is sometimes blurred.  Definitions based 
on DSM IV3 are: 
  Affect.  A pattern of observable behaviours that is the expression of a 
subjectively experienced feeling state (emotion).  Common examples of affect 
are euphoria, anger and sadness.  Affect varies over time, in response to 
changing emotional states. 
  Mood.  A pervasive and sustained emotion that colours the person’s thinking and 
perception of the world.  Common examples of mood include inappropriate 
depression, elation and anxiety. 
Depression has a range of meaning from a lay description of normal unhappiness, 
to a medical description of a psychotic illness.  Research studies using symptom-
rating scales have shown that about 10 symptoms are sufficient to characterise 
depressive states.  These can be divided into core symptoms and other symptoms. 
Core Symptoms 
1. Depressed 
Most of the day, nearly every 
2.  Loss of interest and 
Most of the day, nearly every 
3.  Loss of energy, fatigue 
Nearly every day 
Other Symptoms 
4.  Poor self confidence and 
self esteem 
5.  Ideas of guilt and 
6.  Ideas or acts of self-
harm or suicide 
7. Poor 
         Nearly every day 
attention and 
8.  Psychomotor agitation or 
9. Disturbed 
10. Disturbed appetite 
Diagnosis of a mild depressive episode requires at least two of the three core 
symptoms, plus two of the seven other symptoms.  Over a period of more than 2 
weeks, the symptoms should be present nearly every day, for most of the day, and 
cause disruption of the person's normal activities. 
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Diagnosis of a major depressive episode requires six of the ten symptoms listed 
above.  Negative beliefs such as loss of self-esteem and inappropriate guilt are the 
core symptoms of major depression.  In severe cases, hallucinations and/or 
delusions may occur, the content being consistent with the depressive mood (e.g. 
auditory hallucinations expressing derogatory comments or delusions of guilt).  
These cases are described as major depression with psychotic features.   
In both ICD 10 and DSM IV, major depressive states can be further categorised by 
the presence of physical symptoms indicating a somatic syndrome.   
Somatic (or endogenous) depression is characterised by: 
 Anhedonia 
  Loss of emotional reactivity to pleasurable surroundings and events 
  Early waking (>2 hours early) 
  Psychomotor retardation or agitation 
  Marked loss of appetite 
  Weight loss of >5% of body mass in one month 
  Loss of libido. 
This is in contrast to Reactive Depression, which is not depression that is a 
reaction to circumstances, but depression in which emotional reactivity to events is 
Depression is commonly associated with anxiety disorders. Many patients do not fall 
neatly into categories of either anxiety or depression, so the concept of mixed 
anxiety and depression is now recognised.  The differential diagnosis between 
generalised anxiety disorders and depressive disorders is listed in appendix E. 
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The prevalence of unipolar mood disorder in the community is 5%. 
The prevalence is higher in women (2.0 to 9.3%) than men (1.8 to 3.2%). 
The prevalence of depressive symptoms is much higher, 13 - 20%.   
Community surveys suggest that as many as 16% of older people may be suffering 
from depression, though only a fraction of these may be known to the GP and/or 
psychiatric services.4 
The  incidence of mood episodes in women is 250 – 7,800 new cases / 100,000 
population / year and in men is 80 - 200 new cases / 100,000 population / year. 
In developed countries, the lifetime risk of a depressive episode is 9-26% in women 
and 5-12% in men. 
Sociodemographic Factors  
Depressive disorders can start at any age from childhood onwards.  In women the 
highest prevalence rate occurs between 35 and 45 years and in men the prevalence 
rate increases with age.  Recent trends suggest that depression is becoming more 
common, (or at least being diagnosed more commonly), in younger age groups. 
Overall, depressive disorders are twice as common in women; however due to the 
increasing prevalence with age in men, in the elderly the female:male ratio is 3:2.  
Various explanations for the sex difference have focussed on social hypotheses 
relating to women’s role and status in society and biological differences in hormonal 
effects.  However as these differences are evident in community studies, consistent 
across cultures and persistent over time, the results are unlikely to represent biases 
in help-seeking behaviour.5 
Risk Factors for the Development of Mood Disorders 
  Vulnerability to the development of major depression has strong genetic 
  The heritability of major depression has been estimated at about 40%, however 
estimates of up to 70% have been quoted.6 
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Childhood Experience  
Lack of parental care (as opposed to loss of a parent) is a consistent risk factor for 
the development of a depressive disorder as an adult.6 7 
  Childhood sexual abuse is a risk factor for adult major depression. 
  Cumulative childhood disadvantage poses a greater risk of depressive disorder 
than any single childhood variable in isolation. 
Marital Status 
  For men, married men have the lowest rate of depression, whilst separated or 
divorced men have the highest rates of major depression.  In women the 
association is less clear.6 8  
  The nature of the association between marital status and depression is less 
clear.  Depression may contribute to marital breakdown, or the stress of 
separation or divorce could precipitate a depressive episode. 
Social Environment 
  Studies by George Brown of working-class women from inner London boroughs 
from1975 onwards9 10 11 12 identified having three or more children, a lack of paid 
employment and the lack of a confidant as vulnerability factors for depressive 
episodes.  Subsequent studies have shown only lack of a confidant to be a 
consistent risk factor.6 
  Adverse life events, especially those characterised by loss, increase the risk of a 
major depressive episode.13  The increased vulnerability to a depressive episode 
lasts for a period of 2-3 months following such an event.14 
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The clinical features of a depressive episode can be subdivided into the biological 
symptoms of depression and findings on examination of the mental state. 
Biological Symptoms 
Synonyms: - somatic or vegetative symptoms. 
Sleep disturbance 
a) Characteristically early morning wakening (middle or terminal insomnia) – occurs 
2 – 3 hours before the patient’s usual time. 
b) Also initial (or onset) insomnia – difficulty and delay in falling asleep. 
c)  Some depressed patients sleep excessively – but still feel unrefreshed  on 
d)  Intractable sleep disturbance is common in the elderly. 
Change in appetite 
Characteristically loss of appetite, less commonly increased appetite. 
Change in weight 
Characteristically loss of body weight (at least 5% in a month), less commonly 
increased weight. 
Change in psychomotor activity 
a)  Common in the elderly. 
b)  Characteristically psychomotor retardation (slowed up). 
c) Sometimes agitation. 
Diurnal variation in mood 
a) Characteristically worse in the morning – patients wake up feeling very 
depressed and possibly suicidal. 
b)  Their mood gradually lifts during the day, but is sometimes worse again in the 
Total lack of interest in and enjoyment of hobbies / pleasure activities. 
Loss of interest in work 

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Reduced energy and drive   
Causing fatigue / tiredness and reduced activity. 
Loss of (or markedly reduced) libido 
Change in bowel habit  
Change in menstrual cycle 
Mental State Examination 
 Unkempt 
a)  Neglected dress and grooming 
b)  Poor self-care and personal hygiene – often dirty clothing. 
  Facial features / depressive facies 
a)  Sagging / turning down of the corners of the mouth 
b)  Tearfulness 
c)  “Knitted brow” – vertical furrowing of the centre of the forehead, between the 
d)  Downward gaze  - poor eye contact and reduced rate of blinking 
But - some patients maintain a smiling exterior while depressed. 
  Weight loss.   
 Reduced 
  Shoulders bent and head inclined forwards. 
  Poverty of speech and/or speaking in a monotone. 
  Slow and hesitant – long delay before questions are answered. 
  Low and sad – often one of misery. 
  Qualitatively different from one of unhappiness. 
  “Autonomous” – i.e. loss of reactivity to circumstances. 
  Anxiety, irritability and agitation may occur. 
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Morbid/pessimistic thoughts 
  Concerned with the past: – often taking the form of unreasonable guilt and self-
blame about minor matters, e.g. feeling guilty about past trivial acts of 
dishonesty (such as taking home an office pencil many years ago).  Such minor 
misdemeanours may be exaggerated out of all proportion and used as “proof” 
that the patient is “evil” and does not deserve his current status in life. 
  Concerned with the present: - 
a)  Pessimism - the patient sees the unhappy side of every event. 
b)  He thinks he is failing in everything he does and that other people see him as 
a failure. 
c)  Low self-esteem - he no longer feels confident, and discounts any success 
as a chance happening for which he can take no credit. 
  Concerned with the future (which seems bleak): 
a)  Ideas of hopelessness and helplessness - the patient expects the worst. 
b)  Often accompanied by the thought that life is no longer worth living and that 
death would come as a welcome release. 
c)  May progress to thoughts of, and plans for, suicide. 
d)  Homicidal thoughts may occasionally occur: - e.g. a depressed mother may 
decide the future is equally bleak for her children and plan to kill them before 
committing suicide; or a depressed elderly man may persuade his wife to 
enter into a suicide pact. 
Poverty of thought 
Few thoughts – these lack variety and richness, and seem to move slowly through 
the mind. 
  Impaired attention and concentration. 
  Poor memory – not permanent, as is often feared by the patient. 
  In the elderly, depressive pseudodementia may occur. 
Physical Symptoms 
  Aching discomfort anywhere in the body. 
  Increased complaints about any pre-existing physical disorder. 
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Psychotic Features of Depression 
These occur in more severe episodes of depression: - 
1. Delusions 
a)  Concerning themes of worthlessness, guilt, ill health (especially cancer) or 
b)  Concerning persecution (e.g. that others are going to take revenge on him); 
the supposed persecution is often accepted as having been brought on 
2. Hallucinations 
a)  Usually mood-congruent, derogatory, second-person auditory hallucinations 
– voices addressing repetitive words and phrases to the patient, confirming 
his ideas of worthlessness (e.g. “You are an evil sinful man; you should die”), 
making derisive comments or urging suicide. 
b)  A few patients experience visual hallucinations, such as scenes of death and 
Depressive Stupor 
  Episodes of being unresponsive, akinetic, mute and fully conscious.  Rare with 
modern treatment. 
  After an episode of stupor, the patient can recall events that took place and their 
mood at the time. 
  Periods of excitement may intervene between episodes of stupor. 
Other Psychiatric Symptoms 
  Features of anxiety, e.g. tension, apprehension and phobic, obsessional or 
hysterical symptoms. 
  Hypochondriacal preoccupations – these (and other somatic complaints) are 
common in old age. 
 Depersonalisation. 
Major depressive episodes and episodes of psychotic depression may have some or 
all of the following investigations performed, in order to exclude the differential 
diagnoses listed below. 
1.  Urea and electrolytes, full blood count, thyroid and liver function tests. 
2.  A drug screen – if psychoactive substance use was suspected as a cause. 
3. Vitamin 
B12 and folate levels; syphilitic serology. 
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4.  EEG and/or CT scan if clinically justified. 
5.  In the elderly, hearing and vision tests - to exclude sensory deprivation 
Differential Diagnosis 
Secondary mood disorders can occur in various psychiatric conditions described in 
separate protocols.  In such cases, the primary illness should be treated, with 
symptomatic treatment being given for the secondary mood disorder: 
Organic Disorders 
Cushing’s disease, dementia, hypothyroidism or 
Substance Use Disorders  Alcohol or drug misuse. 
“Negative symptoms” and the pre-morbid phase of 
schizophrenia may be difficult to distinguish from 
depression.  In such cases, a careful search should be 
made for other features of depression, such as the 
biological symptoms.  . Depression is commonly co-
morbid with schizophrenia, both in the acute phase 
and after an episode of schizophrenic illness – post-
schizophrenic depression. 
Appendix F describes the differential diagnosis 
between generalised anxiety and depressive 
Mood disorders are commonly co-morbid with other psychiatric disorders.  In one 
study of American psychiatric outpatients with unipolar major depressive disorder, 
65.4% had at least one other psychiatric disorder.15 
Co-morbidity is important as it is associated with a longer duration of the depressive 
episode, more psychiatric morbidity and more social and occupational impairment.  
The greater the number of co-morbid conditions, the greater the psychiatric and 
psychosocial impairment.15 
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Other Types of Depression 
Postnatal Depression 
Non-psychotic postpartum psychiatric disorders are usually taken to include those 
with an onset up to about 12 weeks after delivery.   
  Post-natal depression (PND) affects about 10% of women in the early weeks 
postpartum, with episodes typically lasting 2-6 months.  Residual symptoms are 
common up to a year after delivery.16 
  PND is more common with increasing maternal age and lower social class. 
  Most receive no treatment at all, or treatment from their GP.  Fewer than 1% see 
a psychiatrist. 
  There is little evidence to support a biological basis to PND.16 
  The presence of 'baby blues' in the immediate postpartum period appears to be 
related to the subsequent development of PND but no hormonal basis has been 
  Obstetric factors are important in a sub group of vulnerable women.  Women 
with a previous history of depressive disorder who experience complications 
during delivery have higher rates of postnatal depression.   
  The major aetiological factors are of a psychosocial nature.  Stressful life events, 
unemployment, marital conflict, and the absence of social and personal support 
have all been shown to raise the risk of PND.  The absence of social support 
and a history of depression approximately double the baseline risk of developing 
  Women who experience PND as their first experience of a mood disorder are at 
greater risk of developing PND in subsequent pregnancies (but not of non-
postpartum depression).17 
Clinical features 
  Despondency, tearfulness and irritability are typically seen. 
  Fatigue, anxiety and phobias often occur (e.g. fears about inability to cope with 
her baby and her own health). 
  Feelings of inadequacy and confusion, as well as difficulty in sleeping and 
concentrating are common. 
  A poor appetite is also common, as is decreased libido (which may be the main 
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  The depression itself may be mild and somatic symptoms may be more 
  Symptoms are often worse at night, creating a vicious cycle of worry and 
  Improved detection of PND can been facilitated by the use of the Edinburgh 
post-natal depression scale.  The scale is used as a screening device by health 
visitors in the post-natal period.16 
  In 90% of sufferers, PND is a self-limiting condition, often lasting less than a 
month, even without treatment. 
  Non-directive counselling provided by trained health visitors has been shown to 
be effective.16 
  There is no systematic evidence to support the use of progesterone. 
  Fluoxetine has been shown to be effective in the treatment of PND.16 
  In about 6%, the depression lasts at least 6 weeks, but in less than 5% does it 
persist for longer than a year.  Hence, less than 5% may be certified unfit for 
work (after their Maternity Leave) and thus claim Incapacity Benefit. 
Seasonal Affective Disorder 
  In some people, there is a regular relationship between the onset of depressive 
episodes and a particular time or season of the year.  Depression usually starts 
in the autumn or winter and ends as daylight hours increase in the spring or 
summer.  This pattern is widely known as seasonal affective disorder (SAD), but 
is more correctly termed seasonal mood disorder.   
  Variations in day length are thought to modulate the rhythmic secretion of 
melatonin by the pineal gland.  The rate-limiting serotonin N-acetyltransferase 
step is probably stimulated at night by the suprachiasmatic nucleus of the 
hypothalamus acting as an endogenous pacemaker and thus as a biological 
clock.  Patients with SAD (and bipolar depressive disorder) have been found to 
have an increased sensitivity of melatonin biosynthesis to inhibition by 
  During depressive episodes patients with SAD frequently exhibit an increase in 
appetite and weight, often with carbohydrate craving, hypersomnia and a 
reversed diurnal variation in mood (at its lowest later in the day), which are 
opposite to the somatic symptoms of other forms of depression.18  
  SAD does not include cases in which distinctive seasonal psychosocial 
stressors, such as regular winter unemployment, cause depressive episodes 
each winter. 
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Mixed Anxiety and Depressive Disorder (Anxiety Depression) 
  Anxiety-depression (AD) is frequently seen in primary care but rarely seen by a 
  Symptoms of anxiety and depression are both present but do not reach 
diagnostic criteria for either a depressive episode or anxiety disorder.  Appendix 
E demonstrates the theoretical differential diagnosis between pure anxiety and 
pure depressive disorders. 
  Mixed anxiety and depressive disorder is frequently misdiagnosed as a 
generalised anxiety disorder. 
  If the symptoms are associated with a stressful life event, then a diagnosis of 
adjustment disorder should be considered (see protocol on adjustment disorder 
and PTSD). 
 Treatment is best undertaken by counselling, cognitive therapy or 
psychotherapy, especially interpersonal therapy 
  Antidepressant medication, especially the selective serotonin re-uptake inhibitor 
antidepressants (SSRIs), may be used. 
Depression in the Elderly 
In the elderly, depression may present atypically in ways that include: - 
1.  Agitated depression – with purposeless activity due to anxiety (e.g. pacing the 
floor or fidgeting); this contrasts with the retardation more commonly seen in 
younger patients. 
2.  Symptoms masked – by concurrent physical illness or minimisation / denial of 
low mood. 
3.  Hypochondriasis – complaints disproportionate to organic pathology / pain of 
unknown aetiology. 
4.  Complaints of loneliness
5.  Onset of neurotic symptoms
6.  Behavioural disturbance – e.g. food refusal, aggressive behaviour, shoplifting or 
alcohol abuse. 
Antidepressants are usually tried first, but there are several problems with their use 
in the elderly.  Lower doses of tricyclic antidepressants (TCADs) are needed owing 
to a longer half-life (reduced distribution-volume and clearance); their anticholinergic 
side effects reduce compliance and worsen pre-existing somatic problems, such as: 
postural hypotension (falls, myocardial or cerebral infarction); dry mouth (dentures 
difficult); urinary retention (anuria); impaired concentration and memory (delirium).  
The SSRIs and RIMAs (see 5.1) are generally better tolerated than TCADs. 
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In resistant cases, ECT (to which elderly depressed patients respond particularly 
well) is used.  Socially isolated elderly depressed patients are at a very high risk of 
committing suicide, so they need close observation and energetic treatment. 
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The majority of depressive episodes can be treated in the community by GPs.  
Referral to Mental Health Teams or Psychiatric outpatients is indicated if the 
depression is severe, failing to respond to treatment or complicated by other factors 
such as personality disorders.  Patients suffering from psychotic and severe mood 
disorders may be admitted to hospital.  Compulsory admission may be necessary in 
cases of high suicidal risk or where poor intake of food and fluids is life threatening. 
Mild, moderate and severe depression are treated in similar ways and the principal 
decision is whether to treat with antidepressant drugs or a talking therapy.  Surveys 
in primary care have shown that most patients would prefer a talking therapy. 
Antidepressants and cognitive behaviour therapy are equally effective in treating 
mild to moderate depression.  In severe depression, antidepressant drugs are more 
Antidepressant Medication  
Drug treatment is effective in moderate and severe episodes of depressive disorder.  
There is a wide and increasing range of antidepressant drugs available, varying in 
their side effects, toxicity and cost. 
Most available antidepressants are equally effective if given at an adequate 
dose for a sufficient period of time
Non compliance with antidepressants may reach 50%.19 
The recommended duration of antidepressant treatment for an initial depressive 
episode has increased over recent years.  Guidelines produced by the British 
Association for Psychopharmacology suggest antidepressant treatment should be 
continued for 6 months following remission,20 however emerging evidence suggests 
continuing treatment for 9-12 months following remission.21 22  Following this, 
antidepressants should be withdrawn gradually over 3 months. 
Antidepressants are effective prophylaxis for recurrent depression and are indicated 
where there is clear risk of further episodes.  The risk of further depressive episodes 
increases with the number of depressive episodes experienced and increasing age 
of onset of depression.  In those with onset of a major depressive episode after 50 
years of age, or with three previous episodes of depression, it is recommended that 
antidepressant medication is continued indefinitely.19  
There are two main classes of antidepressant in common use, the selective 
serotonin re-uptake inhibitors (SSRIs) and the tricyclic antidepressants (TCADs).  A 
third group, the monoamine oxidase inhibitors (MAOIs) have become less popular 
recently as safer alternatives are now available.  They all achieve an antidepressant 
effect by increasing monoamine activity in the central nervous system.   
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All have a slow onset of action, so patients should be warned that it might be 2-3 
weeks before they start to notice any benefit.  The dose should be titrated to the 
maximum dose tolerated before considering a different drug. 
Selective Serotonin Re-uptake Inhibitors  
  For example Fluoxetine, Paroxetine, Sertraline, Citalopram and Fluvoxamine.   
  Act by inhibiting the re-uptake of serotonin into the pre-synaptic nerve cell.   
  Have little or no effect upon noradrenergic processes: no daytime sedation in 
most cases, far less anticholinergic and clinically significant cardiovascular side 
effects than TCADs.  Hence they are better tolerated and safer in overdose; 
also, their onset of action is more rapid. 
  Side effects include nausea, diarrhoea, headache, insomnia, agitation and 
sexual dysfunction. 
Tricyclic Antidepressants  
  Widely used since the 1950s, and still commonly prescribed.  They act by 
inhibiting the re-uptake of the monoamine neurotransmitters noradrenaline and 
serotonin into the pre-synaptic nerve cell. 
  Sedative (e.g. amitriptyline, clomipramine and dothiepin): useful for agitation and 
initial insomnia.   
  Less sedative (e.g. imipramine & lofepramine): useful when lethargy and apathy 
are problems. 
  Side effects - Arrhythmias, heart block, postural hypotension, drowsiness, 
convulsions, paralytic ileus and blood dyscrasias – hence dangerous in 
overdose and can cause death.  Their anticholinergic actions cause blurred 
vision, dry mouth, constipation and urinary retention, so they are contra-
indicated in glaucoma, pyloric stenosis and prostatic hypertrophy.  All of these 
impair compliance, and some can be dangerous for patients being treated in the 
community, such as drowsiness and blurred vision for those who drive, operate 
machinery or work at heights. 
Comparison of TCADs and SSRIs 
As TCADs and SSRIs are equally effective, the choice of drug for each patient 
depends on other factors such as side effects, safety in overdose and cost, as well 
as the range of presenting symptoms. 
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Onset of action  Take 2-3 weeks for benefit to 
Effect begins within 1-2 weeks.
Side effects 
Sedation (may provide relief 
Generally better tolerated – no 
for patients with marked 
cognitive impairment, weight 
insomnia or anxiety).  
gain or anticholinergic effects.  
Autonomic effects (dry mouth, 
Nausea, GI disturbance, 
postural hypotension, urinary 
headaches and sexual 
hesitancy, constipation, sexual  dysfunction may occur 
Safety in 
Cardiotoxic, may cause death 
Safe in overdose and the 
if taken in overdose. 
treatment of choice for patients 
(Lofepramine is an exception.)  at risk of suicide. 
Worse - more side effects. 
Better – fewer side effects. 
Expensive. Benefits due to 
improved compliance and 
reduced cardiotoxicity may 
offset some of the additional 
Other re-uptake inhibitors 
Selective Serotonin and Noradrenaline Re-uptake Inhibitors (SNRIs) - e.g. 
venlafaxine.  Compared with TCADs, SNRIs have far fewer side effects.  Their more 
rapid onset of action (within 2–4 weeks) makes them especially effective for 
depressives with melancholia, anxiety, retardation or agitation. 
Selective Noradrenaline Re-uptake Inhibitors (NARIs) - e.g. reboxetine, are 
useful for alleviating the negative symptoms of depression. 
Noradrenaline and Selective Serotonin Antidepressants (NASSAs) - e.g. 
mirtazapine.  Side effects of nausea, insomnia, anxiety, agitation or sexual 
dysfunction reported less commonly. 
Monoamine Oxidase Inhibitors (MAOIs) 
E.g. phenelzine.  Irreversibly inhibit MAO-A and MAO-B, preventing the breakdown 
of monoamine neurotransmitters and prolonging their action.  To prevent a 
potentially life-threatening hypertensive crisis, they require adherence to an α-
tyramine free diet (excluding, for example, hard cheeses, yeast extracts, broad bean 
pods, and red wine) which is unpopular with patients; as well as avoidance of certain 
drugs, e.g. SSRIs, pethidine, l-dopa and amphetamine.  Their use has been 
superseded by: 
Reversible Inhibitors of Monoamine-Oxidase type A (RIMAs) 
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E.g. moclobemide, brofaromine, cimoxatone, & toloxatone.  Fewer systemic effects: 
less risk of drug or dietary interactions than MAOIs; shorter washout period needed 
for transfer to other antidepressants. 
Other Antidepressant Drugs 
5HT2 antagonists  (e.g. nefazadone) have beneficial effects on sleep architecture 
and sexual function compared with SSRIs. 
Tetracyclic antidepressants  (e.g. mianserin, maprotiline) have a sedative profile, 
but cardiovascular and anticholinergic side effects much less than with TCADs; also 
rarely cause convulsions, so they are safer in overdose. 
Trazodone  has anti-serotonin and α2-receptor antagonist properties, but does not 
block noradrenaline re-uptake.  It has fewer anticholinergic side effects than TCADs 
and a sedative effect useful against concomitant anxiety. 
Flupenthixol  in low dosage can relieve symptoms of apathy, lowered mood, 
asthenia, despondency, and lack of initiative or inertia. 
Mood Stabilisers - Lithium 
The evidence for using lithium in unipolar / recurrent depression is less clear than in 
bipolar disorders.  It can be effective in the acute stage of depression when other 
measures have failed, e.g. in patients who have not responded to a cyclic 
antidepressant drug.  It enhances the effect of TCADs and MAOIs. 
Electroconvulsive Therapy (ECT) 
ECT entails administrating an electric charge to the head of a patient under a 
general anaesthetic in order to produce a generalised convulsion.  The therapeutic 
agent is the convulsion; a normal course is 6–12 treatments at a rate of 2-3 per 
The risk of death is similar to that of general anaesthesia for minor procedures, 
about 2 deaths per 100,000 procedures.  There is no evidence that it causes brain 
damage or permanent intellectual impairment.  Unilateral ECT is less likely to cause 
memory loss. 
ECT is reserved for cases of resistant depression unresponsive to 
pharmacotherapy, especially those with psychotic or marked biological symptoms.  
The presence of biological and psychotic features of depression predicts a good 
response to ECT.   
ECT produces a more rapid resolution of depression compared to antidepressant 
medication and may be lifesaving in severe depression.  However antidepressant 
medication should be continued following a successful course of ECT. 
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In extremely rare cases of chronic disabling depression, when all other treatments 
have failed, the extreme option of psychosurgery may be considered.  About 50 
operations are performed each year in the UK, (involving the implantation of yttrium 
seeds into the forebrain, just in front of the 3rd ventricle). 
For those patients with SAD, where the onset of depression is in the autumn or 
winter months, treatment with high-intensity light is possible.   
Psychosocial Treatments 
Much of the depression treated in primary care is amenable to simple counselling 
using problem-solving techniques, which can be performed either by the GP, a 
psychologist, CPN, or counsellor.  Problem solving treatment is most likely to benefit 
patients who have a depressive disorder of moderate severity and who wish to 
participate in an active psychological treatment.  The combination of problem solving 
treatment and antidepressant medication is no more effective than either treatment 
Employing practice-based counsellors may enable patients with moderately severe 
depression to recover faster, and non-directive counselling appears to be as 
effective as cognitive behaviour therapy (CBT) within this setting. 24 
Cognitive-Behaviour Therapy 
Cognitive-behaviour therapy (CBT) refers to a group of therapies that include 
behaviour therapy, behaviour modification and cognitive therapy in various 
Cognitive therapy explores how thoughts can alter feelings and behaviour.  Therapy 
consists of identifying automatic negative thought patterns (such as hopelessness or 
guilt) and teaching the patient to recognise and challenge them.  The aim is to 
enable the patient to counter the negative thoughts with alternative rational thoughts. 
Behaviour therapy analyses behavioural aspects of the patient's problem, followed 
by the use of techniques to change behaviour, which are tailored to the individual 
CBT helps prevent further attacks of depression by teaching patients how to 
counteract a relapse in the early stages.   
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A full course of cognitive therapy consists of 10-20 one-hour sessions with an 
appropriately trained behaviour therapist and so is an expensive alternative to 
A short course of CBT or non-directive counselling has been shown to enable 
patients with moderately severe depression to recover more quickly and is more 
cost effective than usual GP care (discussion and medication) in the short term (<12 
months).  However there were no significant differences between treatments in 
either outcomes or costs at 12 months.24 26 
Other Psychotherapies 
These include group therapy; brief focal psychotherapy (after bereavement or other 
specific trauma); psychodynamic or psychoanalytic psychotherapy; and, when 
appropriate, family or marital therapy.  All can be used in combination with 
Increased Activity and Social Contact 
Depressed patients should be encouraged not to withdraw totally from work and 
social activities, and should be encouraged to increase such activities (and exercise) 
as soon as their condition allows.  Meeting other people and developing confiding 
relationships has a protective function in preventing relapse.  Voluntary agencies 
can provide support and practical help with a variety of problems (e.g. by 
befriending), which promotes remission,27 and there are several self-help groups 
available for those with depressive disorder (e.g. Depressive Alliance) which provide 
information, support and an opportunity to make social contacts.   
Some patients will benefit from the involvement of a Social Worker, who can help 
with housing and financial problems:  
1.  Accommodation: There is a wide range of accommodation available to people 
with mental health disorders.  Most patients live in independent 
accommodation.  Supported accommodation (e.g. warden-controlled flat, 
hostel, group home or nursing home) is usually necessary only for those with 
severe illness, especially those who have required frequent or lengthy 
admission to hospital.  The Social Worker may help find suitable 
accommodation and arrange funding if necessary. 
2.  Financial assistance: Many depressed patients live in poverty and many more 
have financial problems of some sort.  Financial worries can be precipitating or 
maintaining factors in depressive disorders.  Depression can also be the cause 
of financial problems, as it reduces patients’ ability to earn money and manage 
their financial affairs.  They may need to improve their budgeting skills.  The 
Citizen's Advice Bureau or a Social Worker can provide advice regarding 
managing debts. 
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Occupational Therapy 
Patients with severe or chronic depression may have little to fill their time and if left 
with nothing to do, their depression is likely to deteriorate.  Providing the patient with 
a structured programme of activity will help maintain their motivation and may 
distract them from their symptoms.  Additional goals are to enable depressed 
patients to learn to cope with activities of daily living (such as personal and 
household care), and to improve their social and occupational skills.  Such 
programmes are usually devised by Occupational Therapists, making use of 
community leisure and educational facilities as well as day centres and community 
outreach programmes provided specifically for patients with mental illness. 
Sheltered employment programmes provide a useful stepping-stone back to 
mainstream work. 
Psychiatric rehabilitation services were introduced in the 1960s, as the large 
psychiatric asylums began to be closed down, to help institutionalised long-term 
patients adjust to life in the community.  Even though patients now spend much 
shorter periods in hospital, institutionalisation still occurs, causing secondary 
disability that exacerbates the disability due to severe depression: so rehabilitation is 
often still needed before discharge.  The aims are to teach patients the skills they 
need to cope outside hospital; then gradually to reintroduce them to life in the 
community, usually with psychosocial support as above.  Some outpatients may also 
benefit from further rehabilitation, such as patients who are coping poorly in the 
community but do not yet need readmission, and those who are functioning well in a 
group home but want to move on to less supported accommodation. 
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The prognosis for individual episodes of mood disorder is generally good. 
  Mild cases tend to improve with minimal intervention. 
  About 70% with moderate to severe illness begin to respond to treatment within 
6 weeks; without treatment, the majority can expect to recover eventually, 
although the natural course tends to be about 1-2 years. 
  Non recovery at 1 year from a major episode of depression, is associated with 
the following baseline variables: higher state anxiety and depression scores, a 
lifetime anxiety disorder, higher scores on measures of personality functioning in 
clusters A and C and the reporting at baseline of life event stressors.28 
  The presence of social support, increased security, and increased hope (arising 
from a lessening of a difficulty or deprivation) are associated with recovery or 
improvement in depression.29  
  "Fresh-start” experiences, absence of new severe stressors (life-events and 
other difficulties) and a standard attachment style (to husband or partner) are 
important predictors of remission.30 
However, in the long term, the outcome is less favourable: 
  12-20% of patients with unipolar depression develop chronic depression, that is 
they remain fully symptomatic 2 years after the onset of the initial depressive 
  A cohort of patients followed for 15 years showed that of those who recovered 
from an initial depressive episode, 85% had a further depressive episode.  Of 
those who remained well for 5 years following the index episode, 58% 
experienced a recurrence.31 
  The median number of depressive episodes experienced is four.22 
  Predictors of a recurrence of a mood disorder which have been described are: 
female sex;31 32 a previous depressive episode,31 32 negative attitude to one's 
own occupation;32 increasing age at initial onset;33 and duration of depression 
prior to initiation of treatment.33 
  Co-morbidity is an important prognostic factor.  A co-existing anxiety disorder 
(especially social phobia) indicates risk for persistent depression in primary care 
patients with major depression.34  Another study suggests that it is the burden of 
co-morbidity (i.e. the number of co-morbid conditions) rather than any particular 
disorder that is strongly predictive of functional impairment.15 
In later life, depression doubles mortality, reflecting partly the association between 
depression and physical illness, and partly the increased incidence of suicide.  
The lifetime risk of suicide is as high as 15% in those with severe illness.4 
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Main Disabling Effects 
In the developed world, the burden to society of unipolar major depression quantified 
by disability adjusted life years (DALY)1 is second only to ischaemic heart disease, 
and is predicted to become the leading individual illness by 2020.35 
In terms of disability2 alone, unipolar major depression ranked first in 1990, affecting 
51 million people and accounting for 10.7% of the total years lived with disability 
from all causes.36  Within the community, major depression is associated with  a 
diminished level of physical and mental functioning, higher use of health services 
and more days lost from work and normal duties.37  Recovery from depression is 
associated with significant reductions in work disability.38 
In general, the degree of disability (and thus the level of interference with daily 
activities, including work) correlates with the severity of the depressive episode.  
Many claimants presenting for disability assessment have a lesser degree of 
depressive disorder – towards the mild end of the spectrum.  It is important to 
separate the diagnosis from functional impairment, since many depressed patients 
on treatment may function well with regard to daily activities. 
For all benefits, all available information should be used to obtain a picture of how 
the claimant’s function is currently impaired on an average day.  Information from 
the spouse, son, daughter, carer or other person accompanying the claimant is 
In severe depressive disorder, continuous supervision is necessary in cases where 
there is substantial risk of suicide or self-harm.  This can usually only be reliably 
provided on a 24-hour basis in a hospital setting.   
In those people with severe depressive disorder displaying self-neglect, there may 
be an inability to maintain adequate levels of nutrition and cleanliness.  Performing 
essential domestic tasks, or coping with day to day transactions and communicating 
with others generally are all likely to be significantly affected. 
First depressive episodes of this severity are likely to last a few months at most.  
Any recurrent severe episode is likely to show response to treatment in 6 to 12 
Apart from the rare occurrence of depressive stupor, depression does not affect the 
physical ability to walk.   
Mild purely depressive episodes are unlikely to result in significant disability.  
However, mild depression may be associated with anxiety, phobias, or obsessive-
compulsive features, in which case, any functional impairment is likely to be 
determined by the severity of the associated disorder rather than the mild 
1 which expresses years of life lost to premature death and years lived with disability of a specified severity and duration. 
2 defined as the restriction or lack of ability to perform an activity in the manner or range considered normal for a human 
being (WHO). 
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Assessing the Claimant  
The examining doctor should consider the information on file, informal observations, 
medical and psychiatric history, medication and other treatments, typical day, mental 
state examination and, in some cases, physical examination. 
As in every case where the mental health assessment is applied, the doctor should 
consider whether the criteria for exemption on the grounds of severe mental illness 
are met.  The legislation defines a severe mental illness as:  “involving the presence 
of a mental disease which severely and adversely affects a person’s mood or 
behaviour, and which severely restricts his social functioning, or his awareness of 
his immediate environment”.  The Continuing Medical Education Module 10, 
“Exemption Advice at the Examination Stage,” gives the following “positive features 
with which to consider exemption in depressive disorders”: 
1.  History of recent self-harm, especially attempted suicide, may provide a strong 
pointer.  This self-harm is likely to have been in the last 6 months for it to be 
particularly relevant at the examination stage. 
2.  A more distant history of attempted suicide needs to be considered in the light 
of evidence concerning the claimant’s current mental health. 
3.  Evidence of self-neglect. 
4.  Requirement for recent hospital admission [within 6-12 months] and/or current 
day hospital treatment. 
5.  Supervision by community mental health team as well as GP. 
6.  Mental state examination indicating abnormal appearance or behaviour, little 
speech, severe mood disturbance, or a thought disorder. 
7.  Lack of insight and/or poor compliance with treatment or supervision. 
8.  Additional conditions, including personality disorder or alcohol abuse. 
9.  These factors will also have been considered beforehand at the IB-PCA 
exemption (IB113) and IBSK Scrutiny stages, but the paper-based evidence 
may have been insufficient to justify exemption then. 
Moderately Severe Depressive Episode 
In cases of moderate depression not warranting exemption, several mental health 
descriptors are likely to indicate impaired function: - 
1.  Coping with tasks 
Sufferers likely to have difficulty with answering the ‘phone / taking a message; their 
concentration is often poor (3 descriptors); lack of enjoyment of leisure activities is 
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2. Daily 
Such claimants are likely to need encouragement to get up / dress and be 
distressed by fluctuating or low mood; they are prone to self-neglect and sleep 
commonly interferes with their daytime activities. 
3.  Coping with pressure 
It is likely that mental stress contributed to their stopping work; avoidance of routine 
activities and poor coping skills are common; sufferers often give up activities 
because of fatigue / apathy / disinterest. 
4. Social 
Claimants are likely to need help for self-care; their communication is often impaired; 
they are frequently irritable and prefer to be alone. 
Mild-Moderate Depressive Episode 
Claimants with mild-moderate depression, (including those recovering from a more 
severe depressive episode), are likely to score on a smaller number of the mental 
health descriptors given in 7.1.2. 
Mild Depressive Episode 
Claimants with mild depression (including those who have largely recovered from a 
more severe depressive episode), as well as those using the word “depression” to 
describe unhappiness or normal reactions to stressful events, are likely to score on 
only a few mental health descriptors, if any. 
Review Advice 
The longer the history of depression, the longer is likely to be the period before 
review is advised. 
Cases in which exemption is advised for a short-medium term illness are unlikely to 
merit review in less than 12 months.  For more established cases, review advice of 
“not less than 2 years” or “in the longer term” may be appropriate. 
Non-exempt claimants with depression who have been off work for more than 12-18 
months are unlikely to improve significantly in less than 12-18 months.  In more 
longstanding cases, review advice of “not less than 2 years” or “in the longer term” 
may be appropriate. 
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Appendix A - Suicide 

Suicide accounts for about 1% of all deaths every year.  The current suicide rate for 
the general population is 10 per 100,000 per year.   
All mental disorders apart from learning disability and dementia have a significantly 
raised standardised mortality rate (SMR) for suicide.40 Considering psychiatric 
illness as a whole, in all treatment settings, the mortality risk for suicide was 10 
times that expected.  Considering major depression (as defined by DSM III) the 
mortality risk was 21 times that expected.41  
Psychological autopsy studies collect all available relevant information on the 
suicide victim's life preceding his or her death, which is then used to construct an 
overview of suicide.  A recent study in the UK in young suicides, showed a 
psychiatric disorder to have been diagnosed in 70.4% of subjects, commonly 
depressive disorders (55.5%), followed by personality disorders (29.6%).  Co 
morbidity of psychiatric disorders was found in a third of subjects.42  
Epidemiological Trends 
Worldwide (excluding China), the male suicide rate is 2-4 times higher than the 
The suicide rate is higher in the elderly, however in the developed world, rates are 
declining in this age group due to improved social and health services.  Traditionally, 
suicide rates were low in younger age groups, however suicide rates in young males 
increased by over 80% between 1980 and 1992, and although rates have declined 
in recent years, they remain higher than previously.  In contrast, the rate in young 
females has remained static.42  
Suicide has no single cause but is an individual process in which several risk factors 
can be identified: 
Social status 
Educational status 
Marital Status 
Unmarried, separated, divorced, widowed 
Residential status 
Living alone, homeless43 
Employment status 
Unemployed, retired, insecure employment 
Vets (3x rate of general population); farmers, doctors, 
dentists, pharmacists (2x) 
Season and time 
Spring and autumn, weekend, evening, anniversary. 
Life events 
Adverse life events such as losses, separations and 
criminal charges 
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40 – 50% of those who kill themselves have made previous attempts. 
Two thirds of those who commit suicide have seen their GP in the last month. 
A quarter of those who commit suicide are psychiatric outpatients at the time of 
death – half of these have seen a psychiatrist within the previous week. 
Methods Used 
Men use more “successful” or violent methods of suicide, such as firearms, jumping, 
hanging or asphyxiation with car fumes, whereas the most common method used by 
women is self-poisoning with drugs, the effects of which can be unpredictable. 
Patients should be asked about suicidal thoughts since there is no evidence that 
doing so might put the idea into their mind.  The reasons for such thoughts and the 
methods being considered should be explored.  Feelings that life is pointless or that 
there is no future should be taken very seriously.  Evidence should be sought of 
loneliness, reduced or absent social contact and the psychiatric or physical illnesses 
associated with increased suicide risk.  Relatives and/or friends should also be 
interviewed, and information obtained about any losses.   
1.  Hospital admission in cases of serious risk – compulsorily if necessary. 
2.  Removal of anything that could be used in a suicide attempt, e.g. sharp objects 
or a belt / pyjama cord (which may be used as a noose). 
3.  Regular or continuous observation, depending on the degree of risk. 
4.  Consider nursing the patient in nightclothes by day, to make it more difficult for 
them to abscond without being noticed. 
5.  Appropriate treatment of any psychiatric disorder, particularly ECT for a severe 
depressive episode. 
6.  Awareness that patients with psychomotor retardation are at greater risk of 
suicide once their symptoms begin to improve – when they develop the energy 
to carry out the act of suicide. 
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Appendix B - Deliberate Self-Harm - Parasuicide 

The term deliberate self-harm (DSH) is generally used to cover all acts of self-harm, 
self-injury or attempted suicide.  Acts of DSH do not always involve the intention to 
Definition of Parasuicide  
“Any act deliberately undertaken by a patient who mimics the act of suicide, but 
which does not result in a fatal outcome.  It is a self-initiated and deliberate act in 
which the patient injures himself or herself or takes a therapeutic substance in a 
quantity which exceeds the therapeutic dose (if any) or his or her own habitual level 
of consumption, and which he or she believes to be pharmacologically active.”  Thus 
if a patient takes only a small dose, believing it to be lethal, then this is classed as 
parasuicide, even though such a dose is not usually lethal. 
Methods Used 
In the UK, 90% of cases of parasuicide involve deliberate self-poisoning with drugs.  
Substances used in self-poisoning have changed over the years.  There has been a 
steady increase in the use of paracetamol, and a decrease in minor tranquillisers 
and sedatives.  There has been an increase in overdoses of antidepressants over 
the period 1985 -1995, which is thought to reflect their wider prescription in the 
treatment of depression.44  Hence SSRIs are preferred to TCADs for patients at-risk 
of DSH due to their lower toxicity in overdose.   
Paracetamol, which is freely available without prescription, is particularly dangerous 
since an overdose of as little as 10g, (i.e. 20 x 500mg tablets), can lead to severe 
hepatocellular necrosis.  Patients who had not really wished to die may develop 
encephalopathy, haemorrhage and cerebral oedema, and then die. 
The most common form of self-injury is cutting, but it can also include bruising, 
scraping, scratching, burning and other self-inflicted wounds. 
An estimated 142,000 people per year are referred to hospitals in England and 
Wales after DSH.44  
DSH is more common in women than men, however a marked increase in DSH in 
young males has decreased the female:male gender ratio from 1.4 in 1985, to 1.33 
in 1990 and 1.23 in 1995. 
The highest rates of DSH are seen in the age group 25-34 in women and 15-24 in 
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Different problems precede DCH in men and women.  Problems concerning a 
partner, employment or studies, alcohol, drugs or finances were all more common in 
men presenting with DSH.  Problems with family members other than a partner were 
more common in women. 
There is a high incidence of DSH among offenders supervised by the Probation 
Psychosocial Assessment 
The medical seriousness of self-harming behaviour is unrelated to the psychiatric 
seriousness.  The patient’s account of the medication ingested may not be reliable.  
The presence of any predisposing factors and/or associated psychiatric disorders, 
as above, should be established.  All patients attending hospital A & E Departments 
following DSH should be fully assessed. 
A high degree of suicidal intent before the act of parasuicide is indicated by: 
a)  Planning and preparation, e.g. buying equipment or collecting medication. 
b)  Precautions taken to avoid discovery, e.g. doors locked; the act timed to avoid 
disturbance or carried out in isolation. 
c)  No help sought after the act. 
d)  A violent method attempted, e.g. hanging, electrocution, shooting, jumping or 
e)  A final act was performed, e.g. making a will or leaving a suicide note. 
f)  Regret for not having died and still wanting to die
Other factors to assess are: 
a)  A previous history of suicide attempts. 
b)  The patient’s current problems and the social / financial support available to him. 
Following an act of parasuicide, the patient should be treated medically as 
necessary and any psychiatric disorder should be treated appropriately.   
Repetition is a core feature of suicidal behaviour.  Of those who commit suicide, up 
to 40% have had previous suicide attempts.  Of those who deliberately self-harm, 
10-15% eventually die because of suicide.  The risk of suicide after DSH for males is 
nearly twice the female risk, the risk being greatest in the first year.   
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Risk Factors for Suicide following 
Risk Factors for Repetition of DSH 
  High suicidal intent as elicited by    Previous act of DSH 
the above assessment 
  Previous psychiatric treatment 
 Psychiatric disorder, particularly   Dissocial or anti-social personality 
depressive episodes, alcohol  disorder 
dependence, substance use 
disorders, schizophrenia and 
 Alcohol 
dissocial or anti-social personality    Other psychoactive substance use 
 A history of previous suicide  Criminal 
  Low social class 
 Social 
 Unemployment 
  Age > 45 years 
 Male 
  Unemployed or retired 
  Chronic painful illness 
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Appendix C - Bereavement 

Bereavement can occur after any loss event, e.g. the loss of a relative by death, 
unemployment, divorce, or even the loss of a family pet. 
The effects of bereavement can be modified by:  
a)  The significance of the loss – death of a spouse, child or (if the bereaved is 
under 18 years of age) parent. 
b) The suddenness  - unexpected, untimely and/or multiple deaths. 
c) The degree of anticipation. 
d) The degree of dependence or interdependence with the deceased. 
e) The support available before, during and after the loss. 
f)  The degree to which appropriate mourning occurs. 
g)  The material and social consequences of the loss. 
The effects of bereavement can be aggravated:  
a)  If the death involved pain or severe mutilation. 
b)  If the survivor feels responsible / guilty for the death. 
c)  By loneliness and social isolation, especially in the immobile elderly. 
The loss of a loved person is one of the most severe psychological stresses an 
individual can undergo.  It inevitably causes great distress, and can give rise or 
contribute to the onset of psychosomatic disorders.  Such a loss has profound 
effects on the autonomic and endocrine systems, and probably on the immune 
response.  Several studies have shown an increase in the mortality rate, (and 
particularly in deaths from ischaemic heart disease), during the first year of 
bereavement – especially in widowers over the age of 55 years. 
Grief can be defined as those psychological and emotional processes, expressed 
both internally and externally, that accompany bereavement. 
Three characteristic  components  of  grief, manifested at different phases of 
bereavement, are: 
1.  An urge to cry aloud and preoccupation with the deceased, such as: - 
a)  Vivid imagery or being drawn towards mementoes and places connected 
with the lost person. 
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b)  Perceptual disturbances, e.g. transient hallucinations. 
c)  Mummification, e.g. preservation of possessions and/or the deceased’s 
2.  The conflicting urge to inhibit, avoid and minimise these painful antisocial urges 
– distraction (keeping busy) or avoidance behaviour may achieve this. 
3.  An urge to discover and confront the implications of the loss, and to revise the 
thoughts and behaviour that relied on the lost person. 
Phases of uncomplicated grief 
1. Shock and disbelief - often described as a feeling of numbness. 
2. a) Increasing  awareness of loss with painful  pangs  of  grief  (yearning) 
accompanying emotions of sadness  and  anger – the anger felt may be 
denied, especially if there is conflict or ambivalence concerning the 
b) Increased irritability may be intensified by the denial. 
3.  a) Disorganisation and despair as the full reality of the bereavement is 
b) Other  symptoms, indistinguishable from those seen in depression, may 

Sleep disturbance, with early morning wakening. 

Loss of appetite, weight and libido. 

Reduced performance, energy, drive and interest in everyday activities. 
-  Social avoidance, emotional numbness, depressive ideation and 
- Constipation. 

Somatic symptoms of pain or discomfort. 
4.  Reorganisation as the appetites for food, sex and other human needs return, 
and a new identity is discovered. 
Mourning refers to the necessarily lengthy period of culture-bound social and 
cognitive processes through which one must pass in order to return to more normal 
functioning.  Feelings may be hidden because of social pressures not to share grief.  
Regressions are likely at times of anniversaries and other reminders of loss, which 
cause pain that occurs less frequently but remains just as intense. 
Pathological grief 
Pathological (or morbid) grief occurs when there is disruption of the normal 
mourning process.  The expression of grief may be delayed or prolonged.  Such 
disruption may occur in the following situations: 
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1.  Children are particularly vulnerable, because grieving parents or carers may 
miss the grief of the children and thus fail to provide an appropriate environment 
for the children to grieve.  Children may be sensitive to the adults’ distress and 
so hide their own grief.  Uncharacteristic behaviour may be the expression of a 
child’s grief and be misinterpreted by observers. 
2.  Conversely, caring for children or other dependants, or dealing with the practical 
consequences of the loss, may take precedence over individual concerns, 
providing a barrier to proper mourning and disrupting the grieving process. 
3.  Social or family disapproval of the expression or sharing of emotion may inhibit 
mourning.  Such disapproval may be associated with inadequate mourning of 
previous losses and the consequent avoidance of the reawakening of painful 
memories and emotions. 
4.  Separation from the reality of loss may interfere with adequate mourning.  
Involvement of Western-style hospitals may separate a large proportion of the 
population from contact with the reality of death.  Over-reliance on psychoactive 
medication by the bereaved may similarly separate them from the bereavement 
5.  Mental or physical illness and alcohol or substance abuse may delay grief. 
6.  If the loss is due to traumatic circumstances, then post-traumatic stress disorder 
is likely to interfere with normal mourning – characterised by recurrent 
memories or images, which are so painful that people go to considerable 
lengths to avoid any trigger situation.  Social withdrawal may persist, together 
with a continued fantasy relationship with the dead person. 
Facilitation of normal grieving 
The bereaved need reassurance that the normal physical and mental features of 
grief will pass.  They need permission and time to grieve and, later, permission and 
encouragement to stop grieving and face the new challenges and opportunities that 
confront them.  Normal grieving may be facilitated by the extended family, the 
primary health care team, religious organisations and specialist voluntary sector 
organisations such as CRUSE and the Stillbirths and Neonatal Deaths Society 
(SANDS).  True depression may occur in the context of normal grieving and needs 
appropriate treatment. 
Treatment of pathological grief 
Only when grief becomes pathological in its intensity or length do mental health 
services need to be involved.  Specialist treatments include bereavement 
counselling and guided mourning.  Medication may be used if mental illness 
supervenes, but care must be taken that this does not interfere with the grieving 
process.  SSRIs are preferable to TCADs because of the increased risk of suicide 
during bereavement.  β-blockers may reduce the otherwise increased risk of death 
from IHD in bereaved people with known coronary impairment; they also reduce the 
palpitations, which are a common accompaniment of anxiety during the early phases 
of grief. 
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Disabling effects 
“Bereavement” is not an acceptable diagnosis for the certification of incapacity for 
work.  However, if a true mental illness supervenes, then this can properly be 
recorded as the reason for incapacity, and the expected length of disability will be 
related to the nature of this condition. 
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Appendix D - Simplified Version of the Criteria for a 

Depressive Episode 
Based on the criteria given in the International Classification of Diseases version 10, 
World Health Organisation.2  
Major Depressive Episode 
A to must all apply: 
A.  At least 5 of the following have been present for at least 2 weeks, representing a 
change from previous functioning; one of the five symptoms must be symptom 1 
or 2: 
1.  Depressed mood nearly every day for most of the day. 
2.  Markedly diminished interest or pleasure in all, or nearly all, activities nearly 
every day for most of the day. 
3.  Significant weight loss or weight gain when not dieting, or decrease or 
increase in appetite nearly every day. 
4.  Insomnia or hypersomnia nearly every day. 
5.  Agitation or retardation nearly every day. 
6.  Fatigue or loss of energy nearly every day. 
7.  Feelings of worthlessness or excessive or inappropriate guilt nearly every 
8.  Diminished ability to think or concentrate, or indecisiveness, nearly every 
9.  Recurrent thoughts of death or suicide. 
B. 1. No 
Not caused by bereavement. 
C.  No delusions or hallucinations in the absence of mood symptoms for as long as 
2 weeks during the course of the illness. 
D.  Not superimposed on schizophrenia or other psychosis. 
Minor Depressive Episode 
Minor depression is defined as depressed mood or anhedonia, and one other of the 
9 depression symptoms – BC and must also apply. 
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Appendix E - Differential Diagnosis between 

Generalised Anxiety and Depressive 

Generalised Anxiety Disorder 
Depressive Disorder 
Common in early adult life 
Commoner in later adult life 
Onset age 20–40 years 
Onset age 20-60+ years 
More frequent in those of premorbid 
More frequent in those of previous 
anxious personality 
stable personality 
Previous episodes of anxiety 
Previous episodes of depression or even 
Panic attacks frequent 
Panic attacks uncommon 
Lack of concentration 
Loss of interest (anhedonia) 
Minor loss of appetite 
Major loss of appetite (or increased 
Sexual performance reduced 
Reduced libido 
No diurnal variation of mood 
Marked diurnal variation of mood 
Initial insomnia 
Early morning wakening 
Somatic symptoms common 
Ideas of reference, guilt and 
hopelessness common 
More related to external precipitants 
Less often related to external 
Chronic course 
Episodic course 
N.B.  (1)  Diagnostic category of neurosis often changes over time and in different 
medical records. 
(2)  90% of individuals with neurosis are labelled as having neurotic 
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